Thursday, June 23, 2011

Even my surgeon has an angle

Once I decided to get gastric bypass surgery it was necessary to choose a surgeon. Luiz and I asked everyone we know in Niterói for a recommendation. Surprisingly, lots of people knew someone who has had this procedure. We got several suggestions, but one surgeon kept coming up again and again.
Dr. W was recommended by two of our doctors, a couple friends and even one of my students who is a doctor. Sealing the deal was the fact that he is among the doctors participating in my health insurance network.

Our first meeting with Dr. W went well. While waiting for our appointment (they were running 40 minutes late) Luiz took the opportunity to tell my whole story to the women waiting alongside us. But as you know, there are few secrets among patients in a doctor’s waiting room in Brazil. The secretary brought us each a glass of water.

Talking with Dr. W felt a bit like talking with a salesman. He asked a few questions of me, but mostly he spent the time touting his Cracker Jack team and the sure success associated with the procedure. He did reference the need for me to make behavioral changes so as not to balloon out again in two years, but mostly he kept moving things forward.

Turns out Dr. W’s team is mostly off the grid. In addition to my appointments with Dr. W I was to make three appointments (each) with a psychologist, a nutritionist and a physical therapist (all on his team) but they do not accept UNIMED insurance and their fee is R$100/visit. It seems pretty clear to me that, since UNIMED requires a referral from each of these professions stating the appropriateness of the procedure, Dr. W hires these specialists to do just that. He has eliminated the unpredictable.

I began to feel like the place was a “Tummy Mill.” Whatever – I still felt confident with the Dr.’s skill (he has done the procedure more than 130 times). And I, too, didn’t want anything less than a positive referral from the other professionals for the procedure.

If you have had to have a bunch of tests done here in Brazil you know that it is YOU that wanders the neighborhood from lab to lab to get the tests, and it is YOU that collects and files the results in a safe place. In my experience results are not sent directly to the doctor. I had my work cut out for me to complete my numerous tests and to keep a file with the growing pile of documents and films listing the results.

When I finally had all the results in hand, we returned to Dr. W’s office for a consult. During the “consultation” Dr. W went through all the documents and entered the results into my data file in his computer. That was it. I had to say, “Excuse me, but are you going to discuss with me the results of these tests? What does each test tell us about my suitability for the surgery?” In one case I said, “Why are so many of the results printed in red ink?” To which he replied, “That means you have high blood pressure.” I said, “So don’t you think you should tell me that? Don’t you think you might want to refer me to a cardiologist for follow up?” Sigh.

I’ve found that doctors here are often focused on getting you in and out quickly, don’t explain things well unless they are asked and are annoyed with patients that have a brain and ask questions (this goes for our experience at the Cancer Institute as well). It seems very old school – just do what they say and say “thank you doctor.”

So my opinion over time of Dr. W has been less than stellar.

Each time I went for a consultation with any of the professionals in his stable I got a stray piece of paper that filled in one more piece of the overall puzzle. What I wonder is – if every patient is basically going to go through a similar process, why not put together three or four pages, double sided, that lays it all out and give that guide booklet to the patient? No. It was all disjointed and a bit confused.

Trust me, the secretary was never busy. She could easily have printed and collated said booklets.

To the team’s credit they host a 3 hour meeting once a month for patients to go and listen to presentations by the members of the team and to ask questions. But I found the meetings more like a Mary Kay sales pep talk than a careful presentation of the details and procedures associated with the surgery.

In the end I didn’t actually go to all three consults with each of the team members, but I didn’t miss anything. I was not going to part with my money that easily.

Then two days before the surgery the secretary just happened to ask, “Have you called to arrange the anesthesiologist?” What!? Who knew? It was our job to call the anesthesiologist and tell him when we needed him (because, of course, the secretary had no time between chatting with her girlfriends on her cell and standing in the hallway talking with the other secretaries in neighboring offices).

So we called the guy and made arrangements to meet so he could get a sense of what he needed to bring to the surgery. While he was examining me (now the day before the surgery) he said, “You’re pretty big. I think we will want to use an extra instrument to ensure there are no difficulties. There will be an extra charge.” “How much?” we asked. “We can talk about that tomorrow,” he said. WTF?

The Brazilian penal code has a section addressing fraud. The first three numbers of that section are 171. There is a popular expression when something is illegal that it “looks like it’s 171.” That was our take on this last minute extra charge.

The day after the surgery the anesthesiologist came to my room and checked in. Mostly he came to show off the shiny stainless steel instrument he used “just to be safe.” “I bought it in America!” he said with enthusiasm. (I was not impressed.) With his voice lowered so my roommate could not hear, he let us know that his additional fee was R$1,000. We firmly asked for a bill (which he did not have prepared) and said we were first going to submit it to our insurance company for reimbursement. He got all freaked out and told us that the insurance company would not cover it. Winking at each other, Luiz and I just smiled and said we were going to give it a try anyway. We offered our phone number so he could call us when his bill was ready. He said “No, no, you just give me a call.” Yeah, right. We’ll get right on that! Ha! What was up with that?
There were a few other bits of shenanigans we came across in the final days, but I’ll spare you.

In the end my experience was (unfortunately) similar to what I have with so many business people here; so often people have an angle, or a gimmick, or a scam to squeeze a few extra bucks out of you. Money is tough to come by in Brazil, no doubt, but thinking I’m getting scammed by my surgeon and anesthesiologist… that’s a bit much.

[I continue to heal well and lose weight at an incredible pace.]


Anonymous said...

Hi. Glad to have discovered you. Glad your surgery was successful and that you are experiencing wonderful success with it. Thank you for the peek into Brazilian culture. In case I end up living there, I intend to go in with eyes wide open. Lived in Bolivia for about a decade, so am accustomed to shady stuff that makes you go "what the h...?"

SN said...

I can't imagine the anxiety you went through preparing for the actual surgery! The lack of communication between the doctor and patient is very 'old school' like you said. I feel the same way with my OB but I found on the last visit if I word the questions like an ignorant fool then I get tons of answers! Playing the game isn't always fun but I feel that I won a round.

Stay strong mentally this week! Ecstatic that you continue to heal.


Donna Jean said...

Very brave man. I'll be looking forward to seeing the skinny photos. Take care you two,
love from DJ

Ray and Gil said...


It's great to hear that your procedure has been a success and that you are healing well.
I will have to say I do not think that shady aspect and tricky last minute fees are a "BRAZILIAN" thing, I have had many instances of dealing with Aetna, Bluecross and other American Health Insurance companies and several different doctor's offices in Florida, Texas, Massachusetts and Rhode Island and I can asure you the last minute "NOT COVERED", "EXTRA MONEY" surprises happen all the time.
I am always waiting to see where is the next "catch".
I can say with confidence that this is a "HEALTH INSURANCE" companies issue and many professionals have learned to "DEAL" with patients frustration by omitting information or telling us last minute, when it's too late to "react".


Jim said...

Ray - I'm not really commenting on what the insurance company does not cover, but rather on how the docs have structured things to milk a little more money out of the situation.

I'm sure Dr. W is frustrated by whatever reimbursement he gets for the procedure. So having his own specialists working for cash (which he surely gets a cut) helps to boost the take.

Tha anesthesiologist was just plain sticking it to us. He probably also resents the small payment from UNIMED and is working a side gig with his shiney toy from America to get more $$ from each procedure.

I certainly do not suggest this is exclusive to Brazil, but it matches my experience with other service providers here.

Ray and Gil said...

I hear you, that sucks, it really sounded like these guys were doing something out of the ordinary to milk some extra cash, too bad.
Sorry, I am so used to be screwed by health insurance companies and doctors who omitt "extra charges" I just get all jacked up when we talk about it.
That is why I think we should have universal health care like in Europe and call it a day! :)


Anonymous said...

Thankfully the end result was achieved: a safe surgery and continued positive results to prove it. But it totally sucks that you had this extra sh*t to deal with!

On a somewhat similar note (but totally different circumstances), we essentially had to pay a bribe in order to get our stuff out of customs else we never see our shipment again.

Of course we were never given an itemized bill regarding the purpose of the "extra fees." We were just told that "this is the only way to resolve this matter."

Hmmmm...sounds highly professional, right? It was certainly a rude awakening during our earliest days in Brazil...


Monica Fielder said...

Hi. Jim, glad to know you are healing well. I am a Brazilian living in Delaware, married to an american. I have been following your blog for a while now and decided to leave a comment. Last summer, I had an abdominoplasty surgery in Brazil, in my home town, Volta Redonda. Taking into account that this type of things are notoriously cheaper in Brazil and that we have outstanding plastic surgeons there I went for it. But guess what? After my surgery, talking to some people in the waiting room that had the very same surgery with the very same doctor as i did, I learned that they paid as less as 2.000 reais less than I had paid. I could only figure out that the reason for that is that I live in US and we are of course "richer" than the other patients. I got a little mad about that and did not question the doctor,after all, I had already paid for it and was coming back to the USA soon, but never again will she see the color of my money for future procedures, in case I want to undergo (unlikely) another plastic surgery. What a shame! Stray strong